[CIS-PAGID] IVIG reaction

[Cunningham-Rundles, Charlotte]

So if I really meant to give someone Ig, I would give them say 1- 5 ml SQ in
the office, which would be 1 gram or even less, by slow push.  There would
be a place in the low doses given each day or two, that would equal the
whole dose you want. That could also be done at home, each day with a small
amount. (and no pump needed)


Charlotte Cunningham-Rundles, MD, PhD
Departments of Medicine and Pediatrics
The David S Gottesman Professor
The Immunology Institute
Mount Sinai School of Medicine
1425 Madison Avenue
New York, NY 10029
Phone: 212 659 9268
Fax: 212 987 5593
Email: Charlotte.Cunningham-Rundles at mssm.edu





> From: "Hare, Nathaniel D" <NHare at Cheshire-Med.COM>

> Reply-To: PAGID <pagid at list.clinimmsoc.org>

> Date: Wed, 15 Feb 2012 18:32:15 -0500

> To: PAGID <pagid at list.clinimmsoc.org>

> Subject: Re: [CIS-PAGID] IVIG reaction

> 

> And yes, both episodes of aseptic meningitis were documented by lumbar

> puncture.

> 

> Nathaniel D. Hare MD

> Allergy & Immunology

> CMC - Dartmouth Hitchcock Keene

> Keene, NH  03431

>  

> ph  (603) 354-5496

> fax (603) 354-5498

> -----Original Message-----

> From: pagid-bounces at list.clinimmsoc.org

> [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Hare, Nathaniel D

> Sent: Wednesday, February 15, 2012 6:21 PM

> To: pagid at list.clinimmsoc.org

> Subject: Re: [CIS-PAGID] IVIG reaction

> 

> As a follow up question though - I have 1 patient with recurrent pneumonia

> (documented), specific antibody deficiency, IgG in the 500's, otherwise normal

> immune evaluation, who has had aseptic meningitis with both IVIG and subQ IgG

> treatment.

> 

> Assuming you have a patient with an appropriate diagnosis of immune deficiency

> that is antibody based, who has severe documented infections, who needs IgG

> replacement therapy, what do you do if they have aseptic meningitis with both

> IV and SubQ IgG replacement?

> 

> I realize you may argue with me about my specific patient's need for IgG

> therapy, but if you could address the question about what to do with aseptic

> meningitis with both product formulations, that would be great.

> 

> Thanks,

> 

> Nathan Hare

> 

> 

> 

> Nathaniel D. Hare MD

> Allergy & Immunology

> CMC - Dartmouth Hitchcock Keene

> Keene, NH  03431

>  

> ph  (603) 354-5496

> fax (603) 354-5498

> -----Original Message-----

> From: pagid-bounces at list.clinimmsoc.org

> [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Nelson, Robert P Jr

> Sent: Wednesday, February 15, 2012 4:31 PM

> To: 'pagid at list.clinimmsoc.org'

> Subject: Re: [CIS-PAGID] IVIG reaction

> 

> Agree with Jack and Charlotte, multiple anecdotes.  Bob

> 

> Robert P. Nelson Jr., MD

> Professor of Medicine and Pediatrics

> Divisions of Hematology/Oncology

> 535 Barnhill Dr. Ste 473

> Indianapolis, IN  46202

> Telephone: 317-948-1186

> E-mail: ronelson at iupui.edu

> pager:  317-312-1773

> 

> 

> -----Original Message-----

> From: pagid-bounces at list.clinimmsoc.org

> [mailto:pagid-bounces at list.clinimmsoc.org] On Behalf Of Cunningham-Rundles,

> Charlotte

> Sent: Wednesday, February 15, 2012 3:58 PM

> To: PAGID

> Subject: Re: [CIS-PAGID] IVIG reaction

> 

> I agree with Jack.  In my experience, the ones that have the most trouble with

> bad reactions over time, are the most likely to not need it....

> 

> I have not collected data on this very rigorously but sure have seen this a

> lot --aseptic meningitis,  admissions to ER etc/....  You may have to persuade

> her to have a better workup first.

> 

> 

> Charlotte

>   

> Charlotte Cunningham-Rundles, MD, PhD

> Departments of Medicine and Pediatrics

> The Immunology Institute

> Mount Sinai School of Medicine

> 1425 Madison Avenue

> New York, NY 10029

> Phone: 212 659 9268

> Fax: 212 987 5593

> Email: Charlotte.Cunningham-Rundles at mssm.edu

> 

> 

> 

> 

>> From: Jack R <jroutes at mcw.edu>

>> Reply-To: PAGID <pagid at list.clinimmsoc.org>

>> Date: Wed, 15 Feb 2012 14:48:44 -0600

>> To: PAGID <pagid at list.clinimmsoc.org>

>> Subject: Re: [CIS-PAGID] IVIG reaction

>> 

>> HI Niraj

>> I am not convinced that she needs Ab replacement. Was there documented

>> sinus disease prior to the initiation of IVIG or just symptoms

>> compatable with sinusitis? Did she have an abnormal specific Ab

>> response to pneumovax? Was she tried on more conservative measures

>> (nasal washes, intranasal steroids) prior to IVIG?

>> 

>> I frequently see patients with symptoms suggestive of

>> recurrent/chronic sinusitis, but no or little abnormalities when I obtain a

>> CT scan.

>> Furthermore, most patients will have a reduction in URIs with IVIG,

>> regardless of whether they have an immune deficiency.

>> 

>> If you are convinced she has specific Ab deficiency and needs

>> replacement therapy, I agree with Elie and would use subcut.

>> 

>> good luck

>> 

>> Jack

>> 

>> 

>> John M. Routes, MD

>> Chief, Section of Allergy and Clinical Immunology Professor of

>> Pediatrics, Medicine, Microbiology and Molecular Genetics Department

>> of Pediatrics Children's Hospital of Wisconsin Medical College of

>> Wisconsin

>> 

>> ________________________________

>> From: pagid-bounces at list.clinimmsoc.org

>> [pagid-bounces at list.clinimmsoc.org] On Behalf Of Patel, Niraj C

>> [Niraj.Patel at carolinashealthcare.org]

>> Sent: Wednesday, February 15, 2012 2:22 PM

>> To: 'pagid at list.clinimmsoc.org'

>> Subject: [CIS-PAGID] IVIG reaction

>> 

>> Dear Colleagues,

>> 

>> I saw this patient for the first time this week, and she has extreme

>> difficulty tolerating IVIG infusions.

>> 45 yo female with lupus since 1994, history of pericarditis,

>> antiphospholipid syndrome, oral ulcers and peripheral neuropathy. She

>> received epratuzumab

>> (antiCD22) for lupus in June 2008 (IgG level prior was 610).  She was

>> started on IVIG in March 2009 for low IgG 530 (normal IgA, IgM) and

>> chronic sinusitis despite. No antibody to vaccines was done.  She

>> initially tolerated IVIG

>> (400mg/kg) for several months (IgG levels in 700-800), until she began

>> developing headaches, vomiting, fever.  No laryngeal swelling,

>> wheezing, or hives.  Despite premedication with 50mg Benadryl,

>> changing IVIG formulations, 20mg demamethasone the night prior and

>> 20mg the morning of infusion, decadron (unknown dose) prior to

>> infusion, and rate slowed to 70cc/hr (15 hour-long infusion), her

>> symptoms worsened. She had aseptic meningitis in May 2011 and Nov 30

>> 2011 thought due to IVIG, although the latter episode occurred 6 days

>> after infusion and no lumbar puncture done either time. Symptoms

>> included fever, neck pain, vomiting, photophobia and was hospitalized for 1

>> week each time and treated with high-dose steroids.

>> 

>> During the almost 2 years on IVIG, she noted remarkable improvement in

>> sinus symptoms and had just 1 sinusitis during this time period

>> (compared to chronic nasal symptoms and antibiotics at least once

>> monthly prior to IVIG).  She stopped her IVIG after Nov 30 2011 due to

>> adverse reaction and her chronic nasal symptoms returned after 4-6

>> weeks.  CT of sinus this week was negative except scant sphenoid fluid

>> and endoscopy of nasal passages was normal (she was on levoquin at that

>> time).  Most recent labs on 1/26/12:

>> 

>> IgG 563 (791-1643)

>> IgA 89 (66-436)

>> IgM 75 (43-279)

>> WBC 9,100

>> ALC 1,065

>> CD19B 53 (90-660)

>> CD3T 809 (690-2,540)

>> CD4T 405 (410-1,590)

>> CD8T 362 (195-1,140)

>> CD56/16 181 (90-590)

>> 

>> 1) Would you restart Ig replacement? Try subQ in a monitored setting?

>> 2) Hold on Ig replacement therapy until more definitive evidence of a

>> chronic infectious process?

>> 3) Could an autoantibody to Ig be present in this setting?  If so,

>> offer rituximab?

>> 

>> Thank you in advance for your help.

>> 

>> Niraj

>> 

>> Niraj Patel, MD MS

>> 

>> Department of Pediatrics

>> Infectious Diseases and Immunology

>>  Levine Children's Hospital

>> Carolinas Medical Center

>> PO Box 32861

>> Charlotte, NC 28232-2861

>> 

>> Tel:   (704) 381-6803

>> Fax:  (704) 381-6841

>> Appt: (704) 381-8840

>> 

>> Email: 

>> 

> 

niraj.patel at carolinashealthcare.org<mailto:niraj.patel at carolinashealthcare.org>

>

>> 

>> 

>> 

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>